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Blue Cross Outpatient Claims Form - MEDICAL INSURANCE


									                                                                                                                                                 22/F., Cosco Tower, 183 Queen's Road Central, Hong Kong
                                                                                                                                                                          183              22
                                                                                                                                                 Tel/      : 2163 1000     Fax/     : 2163 1100

                                      This form is applicable to both inpatient and outpatient surgical claim
Part I - To be completed by the patient
  Name of Policyholder

  Name of Employee/Member              /                                                                                                         Policy No.
  (For group insurance policy only)

  Insured No./Certificate No.              /
  (If applicable        )

  Name of Patient

  Occupation                                                                                                                         Date of Birth                                                Sex
                                                                                                                                     (DD/MM/YY        /    /   )
                                                                                                                                                                                                      M        F

  Relationship to the Policyholder                                                    Self                                           Spouse                                                   Child
                                                                                      Staff/Member        /                          Dependent         /

  (1) Have you had any prior treatment for this or related conditions?                                            ?                                                                      No           Yes

  Date(s)                                             Name of Doctor


  (2) Are you making any other insurance claim as a result of this hospitalization/surgery?                   /                                                                          No           Yes

  Name of Insurance Company

  Policy No.

  (3) Was the hospitalization/surgery a result of an accident?            /                                                                                                              No           Yes

  Date                                         Time                                           Place

  Brief Description

Declaration & Authorization
  I/We hereby declare that the answer to all the above questions are accurate, true and complete and given to the best of my/our knowledge and belief.
  I/We hereby declare and agree that any personal data concerning myself/ourselves collected and held by Blue Cross (Asia-Pacific) Insurance Limited (the Company ) (whether contained in this application or
  otherwise obtained) may be used, stored, disclosed and transferred (whether within or outside Hong Kong) to such individuals/organzations associated with the Company as the Company may consider necessary
  or any selected third party including reinserers, claims investigators, medical facilities and industry associations/federations for the purposes of processing this application and providing subsequent service, and
  to communicate with me/us for such purposes.
  I/We understand that if I/We and/or the Insured(s) fail to provide any information requested in this application, it may result in the inability of the Company to accept or process this application.
  I/We also hereby authorize any organization or individual that has any record or knowledge of my/the Insured(s)'s health and medical history or any treatment or advice that has been or may hereafter be consulted
  to disclose to the Company such information. A photocopy of this authorization shall be as valid as the original.
        /                                                                                                       /
        /                                                                                                                                                         /
                                             /                                                                                                                                /
        /                        /         /
        /                                         /                                                                                     /

  Personal Information Collection Statement
  I / We understand and agree that any personal information collected or held by the Company may be used, stored, disclosed and transferred (within or outside of Hong Kong) to such individuals / organizations
  associated with the Company or any selected third party for the purposes of processing this application and providing subsequent services for this, and promotion of financial products or services by the Company
  and its affiliated companies, and communicating with me/us for such purpose. I / We have the right to obtain the Privacy Policy Statement , access to and to request correction
  of any personal information held by the Company. Such request could be made to Company's Corporate Data Protection Officer at 22/F, Cosco Tower, 183 Queen's Road Central, Hong Kong.
        /                                                                  /                                                                                                                                   /
                                                                                                                                                          /                     /
  183 22                                                                ,

  Date                                                                                                                       Signature of Patient
  (DD/MM/YY           /   /     )

Blue Cross (Asia-Pacific) Insurance Limited                                                                                                                                                                 AH30073/01.03
Part II - To be completed by the attending Physician/Surgeon at the Claimant's Own Expenses
 (1)   Name of Patient

 (2)   Hospitalization
       Name of Hospital

       Date of Admission                                                                         Date of Discharge
 (3)   Surgical procedure

       Date of Operation                                                                         Name of procedure


 (4) Chief complaints of the patient relating to this hospitalization/surgery                /

 (5)   Diagnosis of conditions

 (6)   Brief discharge summary: (including treatments, investigation procedures, results; and/or any complications and follow up plan.)

 (7)   Date of accident occurred or symptom first appeared

 (8)   Date of first consultation for this condition or related illness

 (9)   To the best of your knowledge, has the patient ever had the same or similar conditions or symptoms relating thereto?

          No             Yes              Please state dates and describe

 (10) Is the patient referred by another doctor?
          No             Yes              Name and address of the referral doctor

 Name of Attending Physician / Specialist (with qualifications)                                                Telephone
     /                    (      )


 Signature of Attending Physician / Specialist                                                                 Date (DD/MM/YY)
      /                                                                                                              ( / / )

                            This claim form is endorsed by the Hong Kong Medical Association and Medical Insurance Association of the Hong Kong Federations of Insurers

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